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CREDENTIALING APPLICATION CHECKLIST - Coventry Health

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					                                      CREDENTIALING APPLICATION CHECKLIST
To assist you with preparation of the Coventry Health Care of Illinois, Inc. (“Coventry Health Care”) application, we have de-
veloped the following checklist. Providing a copy of each document (along with the application) will expedite the processing
timeframe. This document must be checked off (), signed and returned with the application, by the person completing the
application, verifying that ALL required documents are provided with the application.


        Completed applicable state credentialing form or current *CAQH#
         (including attached signed and dated Coventry Health Care Consent form.)
        Curriculum Vitae (CV)
        Current copy of active state medical license                                 Exp. Date: ______________________
        Current copy of active state narcotic license                                Exp. Date: ______________________
        Current copy of active DEA license                                           Exp. Date: ______________________
        Copy of Collaborative Agreement for all NPs and PAs (required)
        Current copy of board certification(s)                                       Exp. Date: ______________________
        Signed and dated Coventry Health Care contract(s) (if applicable)
        W-9 Tax Identification Form
        Unique National Physician Identification (NPI) number
        Current copy of liability insurance                                          Exp. Date: ______________________
        Clinical information on malpractice cases in past five (5) years
        Sample CMS 1500 form indicating billing information in boxes 31 and 33

*updated within last 6 (six) months




                     Applications submitted without this form and ALL of the above documents/information
                                           WILL be returned for further completion.



Physician Name: ___________________________________________________
Completed By: ____________________________________________________ Date: ____________________
Phone Number: ( ___________ ) _____________________________________


CHCIL 00245 (9-12)
                                      STATE OF ILLINOIS
  Health Care Professional Credentialing and Business Data Gathering Form

         The Health Care Professional Credentials Data Collection Act [410 ILCS 517]
         requires that this form be collected from health care professionals by hospitals,
         health care entities, and health care plans which desire to credential such
         professional. Each hospital, health care entity, and health care plan may also
         require completion of supplemental forms.



                                                     INSTRUCTIONS

    This form is for initial credentialing only. Other forms are required for recredentialing and
    for updating information. YOU ONLY HAVE TO FILL OUT AND SUBMIT WHAT IS
    REQUESTED BY THE CREDENTIALING ENTITY. PLEASE REFER TO THE
    INSTRUCTIONS PROVIDED TO YOU BY THE ORGANIZATION YOU ARE
    APPLYING TO FOR THEIR REQUIREMENTS.


    This form has been segmented into two (2) different Chapters, each containing various sections:

                  Chapter A:         Practice and Professional Information
                  Chapter B:         Business Information


    As previously noted, please consult the specific credentialing entity instructions for their
    individual Chapter or Section requirements for submission.


    GENERAL INSTRUCTIONS: Wherever this application requests information but does not
    provide sufficient space to provide a complete response (for example, you have more licenses,
    specialties, work history, etc.) provide attachments which contain all of the information requested
    in the relevant section OR duplicate the relevant section as many times as necessary and attach it
    to the back of this application.

    The data marked as “Confidential Information” shall be maintained in confidence to the extent
    required by law. They may be used by the health care plan, entity or hospital and by their agents
    for credentialing and internal business purposes. Other data contained in this form may be
    released.




Health Care Professionals Credentialing & Business Data Gathering Form                                    1
Applicant Name:
                                               ATTACHMENTS

    Attach forms A-F as needed to support “yes” responses in Section J: Professional History
    and copies of the following:


                Curriculum Vitae

            CONFIDENTIAL INFORMATION:
                     All Current Professional Licenses
                     Current Federal DEA License, If Applicable
                     Current State Controlled Substance License(s), If Applicable
                     Current Professional Liability Insurance Face Sheet or Declaration of Insurance with
                     Effective Date, Expiration Date and Amount Displayed per Occurrence and In
                     Aggregate
                     Current CLIA Certificate, If Applicable
                     Current W-9s, If Applicable
                     ECFMG Certificate, If Applicable
                     Professional School Diploma, Residency Certificates, Fellowship Certificates, and
                     Board Certifications, As Applicable



                                 AFFIRMATION OF INFORMATION

I represent and warrant that all of the information provided and the responses given are correct and
complete to the best of my knowledge and belief. I understand that falsification or omission of
information may be grounds for rejection or termination, in addition to any penalties provided by law. I
further agree to promptly inform all entities to which this form was sent and not rejected of any change
required to be updated by the Health Care Professional Credentialing and Business Data Gathering
Update Form.

I understand that this application does not entitle me to participation in any hospital, health care entity, or
health plan.



Applicant’s Signature                                 Type or Print Name                            Date


  **      PLEASE BE ADVISED THAT EACH HOSPITAL, HEALTH CARE ENTITY,                                         **
 **       AND HEALTH CARE PLAN MAY ALSO REQUIRE COMPLETION OF AN                                            **
 **           ATTESTATION AND RELEASE OF INFORMATION FORM.                                                   **




Health Care Professionals Credentialing & Business Data Gathering Form                                            2
Applicant Name:
                                 CHAPTER A:
                   PRACTICE AND PROFESSIONAL INFORMATION

                                  SECTION A. GENERAL INFORMATION

Name:
         Last                                                    First                             MI              Degree
List other names by which you have been known:
                                                      Last                                 First                    MI

If you have been known by other names, please explain why your name changed:



Birth Date:                  Place of Birth:
              (mm/dd/yy)                       City                                State                Country

Sex:     Male            Female    Language Fluency of Applicant:        English       Other:
U.S. Citizen?      Yes       No                                          Spanish
                      If no, do you have a legal right to reside permanently and work in the U.S.?         Yes           No

                                                                                 CONFIDENTIAL INFORMATION
 Resident Visa No:
 Social Security Number:
 Emergency Contact Person:
                                  Last                                   First                                     MI

                                  Telephone Number:          (       )



Mailing Address:
                   Street                                                City                      State          Zip

Daytime Phone: (      )               Fax Number: (      )


E-Mail Address:


Check here if you have appended additional information for this section:




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Health Care Professionals Credentialing & Business Data Gathering Form                                                        3
Applicant Name:
                              SECTION B. PROFESSIONAL INFORMATION

Illinois Professional License Number:
         License Unlimited?     Yes            No            If No, please explain limitation:



Current and Previous Professional License(s) in Other States
   State:                       License #:                                         Exp. Date:              (mm/dd/yy)

         License Unlimited?     Yes            No            If No, please explain limitation:


    State:                            License #:                                   Exp. Date:              (mm/dd/yy)

         License Unlimited?     Yes            No            If No, please explain limitation:



    State:                            License #:                                   Exp. Date:              (mm/dd/yy)

         License Unlimited?     Yes            No            If No, please explain limitation:



    Check here if you have appended additional information for this section:


 Current Federal DEA License Number:                                             CONFIDENTIAL INFORMATION


    DEA License Number Expiration Date:                                       License Unlimited? Yes          No
         If No, please explain limitation:



    Check here if you have appended additional information for this section:

Current and Previous State Controlled Substance Number(s):

                                         CONFIDENTIAL INFORMATION
   State:                                CS License #:                             Expiration Date:
                                                                                                       (mm/dd/yy)
   State:                                CS License #:                             Expiration Date:
                                                                                                       (mm/dd/yy)
   State:                                CS License #:                             Expiration Date:
                                                                                                       (mm/dd/yy)

    Please identify all limitation related to the above Controlled Substances Number(s) and explain
    limitation.




Health Care Professionals Credentialing & Business Data Gathering Form                                              4
Applicant Name:
Medicare Unique Provider ID# (UPIN):
National Provider Identification Number (NPI):
Medicaid ID#:
X-Ray Certification: State:                 Certificate #:                  Expiration Date:                  (mm/dd/yy)


Check here if you have appended additional information for this section:



                                    COMPLETE FOR EACH SPECIALTY

Specialty I:
         Are you Board Certified in Specialty I? Yes              No
         If Yes, name of Certifying Board:
         Date of Certification:                          Date of Recertification (if applicable):
                                  (mm/yy)                                                           (mm/yy)
         If No, have you taken or are you scheduled to take the specialty boards certification? Yes              No
         If Certifying Boards taken, give date:                     Certification Expiration Date, if Any:
                                                  (mm/yy)                                                     (mm/yy)
         If not taken, date scheduled to take Specialty Boards:
                                                                  (mm/yy)


Specialty/Subspecialty II:
         Are you Board Certified in Specialty II? Yes             No
         If Yes, name of Certifying Board:
         Date of Certification:                          Date of Recertification (if applicable):
                                  (mm/yy)                                                           (mm/yy)
         If No, have you taken or are you scheduled to take the specialty boards certification? Yes              No
         If Certifying Boards taken, give date:                     Certification Expiration Date, if Any:
                                                  (mm/yy)                                                     (mm/yy)
         If not taken, date scheduled to take Specialty Boards:
                                                                  (mm/yy)




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Health Care Professionals Credentialing & Business Data Gathering Form                                                     5
Applicant Name:
Specialty/Subspecialty III:
         Are you Board Certified in Specialty III? Yes            No
         If Yes, name of Certifying Board:
         Date of Certification:                         Date of Recertification (if applicable):
                                  (mm/yy)                                                          (mm/yy)
         If No, have you taken or are you scheduled to take the specialty boards certification? Yes            No
         If Certifying Boards taken, give date:                     Certification Expiration Date, if Any:
                                                  (mm/yy)                                                    (mm/yy)
         If not taken, date scheduled to take Specialty Boards:
                                                                  (mm/yy)


Specialty/Subspecialty IV:
         Are you Board Certified in Specialty IV? Yes             No
         If Yes, name of Certifying Board:
         Date of Certification:                         Date of Recertification (if applicable):
                                  (mm/yy)                                                          (mm/yy)
         If No, have you taken or are you scheduled to take the specialty boards certification? Yes            No
         If Certifying Boards taken, give date:                     Certification Expiration Date, if Any:
                                                  (mm/yy)                                                    (mm/yy)
         If not taken, date scheduled to take Specialty Boards:
                                                                  (mm/yy)



Check here if you have appended additional information for this section:




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Health Care Professionals Credentialing & Business Data Gathering Form                                                 6
Applicant Name:
                        SECTION C. PROFESSIONAL LIABILITY INSURANCE

         Please provide information on all professional liability insurance carriers from whom you
         have received coverage in the past 10 years.


 CURRENT PROFESSIONAL LIABILITY INSURANCE

 CONFIDENTIAL INFORMATION:

 Carrier:
 Address:
            Street                                              City                          State       Zip
 Policy Number:                                Original Effective Date:                Expiration Date:
                                                                          (mm/dd/yy)                      (mm/dd/yy)
 Policy Limits: Per Occurrence: $                      Aggregate: $

 Retroactive Date:
                     (mm/dd/yy)
 What type of coverage do you have?          Claims Made          Occurrence
 Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?
                                                                                               Yes                No




 PREVIOUS PROFESSIONAL LIABILITY INSURANCE

 CONFIDENTIAL INFORMATION:

 Carrier:
 Address:
            Street                                              City                          State       Zip
 Policy Number:                                Original Effective Date:                Expiration Date:
                                                                          (mm/dd/yy)                      (mm/dd/yy)
 Policy Limits: Per Occurrence: $                      Aggregate: $

 Retroactive Date:
                     (mm/dd/yy)
 What type of coverage do you have?          Claims Made          Occurrence
 Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?
                                                                                               Yes                No




Health Care Professionals Credentialing & Business Data Gathering Form                                                 7
Applicant Name:
 PREVIOUS PROFESSIONAL LIABILITY INSURANCE

 CONFIDENTIAL INFORMATION:

 Carrier:
 Address:
            Street                                              City                          State       Zip
 Policy Number:                                Original Effective Date:                Expiration Date:
                                                                          (mm/dd/yy)                      (mm/dd/yy)
 Policy Limits: Per Occurrence: $                      Aggregate: $

 Retroactive Date:
                     (mm/dd/yy)
 What type of coverage do you have?          Claims Made          Occurrence
 Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?
                                                                                               Yes                No




 PREVIOUS PROFESSIONAL LIABILITY INSURANCE

 CONFIDENTIAL INFORMATION:

 Carrier:
 Address:
            Street                                              City                          State       Zip
 Policy Number:                                Original Effective Date:                Expiration Date:
                                                                          (mm/dd/yy)                      (mm/dd/yy)
 Policy Limits: Per Occurrence: $                      Aggregate: $

 Retroactive Date:
                     (mm/dd/yy)
 What type of coverage do you have?          Claims Made          Occurrence
 Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?
                                                                                               Yes                No




Health Care Professionals Credentialing & Business Data Gathering Form                                                 8
Applicant Name:
                                  SECTION D. EDUCATION AND TRAINING

          If there are any gaps in your training (greater than 30 days), or if you have not completed
          any portion of your training, please explain on a separate sheet of paper and attach to this
          application.

 MEDICAL/PROFESSIONAL SCHOOL
Institution Name:
Mailing Address:
                    Street                                                   City                   State   Zip
Telephone Number: (          )             Fax Number: (      )
Degree:                            Year Graduated:
Dates attended:      From:                To:
                              mm/yy             mm/yy
If you are a graduate of a foreign medical school, are you certified by the Educational Commission for Foreign
Medical Graduates (ECFMG)?           Yes      No
          Date Issued:                          Serial Number for ECFMG:
                         mm/yy
          Were you the subject of any disciplinary action during your attendance at this institution?        Yes       No
                    (Attach an explanation of a “Yes” answer.)
If you attended more than one medical/professional school, please check here and attach an explanation that
duplicates the information requested above:


 INTERNSHIP
Institution Name:
Department Chair or Program Director:
                                           Last Name                         First Name              MI       Degree
Mailing Address:
                    Street                                                   City                   State   Zip
Telephone Number: (          )             Fax Number: (      )
Dates attended:      From:                To:
                              mm/yy             mm/yy
Type of internship:          Rotating       Straight          If straight, please list specialty:
Did you successfully complete this program?             Yes       No           If no, please attach an explanation.
Were you the subject of any disciplinary action during your attendance at this institution?         Yes           No
                    (Attach an explanation of a “Yes” answer.)
If more than one internship, please check here and attach additional information that duplicates the information
requested above:




Health Care Professionals Credentialing & Business Data Gathering Form                                                  9
Applicant Name:
 FIRST RESIDENCY

Institution Name:
Department Chair or Program Director:
                                          Last Name                       First Name              MI       Degree
Mailing Address:
                    Street                                                City                  State    Zip

Telephone Number: (          )            Fax Number: (      )
Dates attended:      From:               To:
                             mm/yy             mm/yy
Type of residency:
Did you successfully complete this program?            Yes       No         If no, please attach an explanation.
Were you the subject of any disciplinary action during your attendance at this institution?      Yes           No
                    (Attach an explanation of a “Yes” answer.)


 SECOND RESIDENCY

Institution Name:
Department Chair or Program Director:
                                          Last Name                       First Name              MI       Degree
Mailing Address:
                    Street                                                City                  State    Zip

Telephone Number: (          )            Fax Number: (      )
Dates attended:      From:               To:
                             mm/yy             mm/yy
Type of residency:
Did you successfully complete this program?            Yes       No         If no, please attach an explanation.
Were you the subject of any disciplinary action during your attendance at this institution?      Yes           No
                    (Attach an explanation of a “Yes” answer.)
If more than two residencies, please check here and attach additional information that duplicates the information
requested above:




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Health Care Professionals Credentialing & Business Data Gathering Form                                              10
Applicant Name:
 FIRST FELLOWSHIP

Institution Name:
Department Chair or Program Director:
                                          Last Name                       First Name              MI       Degree
Mailing Address:
                    Street                                                City                  State    Zip

Telephone Number: (          )            Fax Number: (      )
Dates attended:      From:               To:
                             mm/yy             mm/yy
Type of fellowship:
Did you successfully complete this program?            Yes       No         If no, please attach an explanation.
Were you the subject of any disciplinary action during your attendance at this institution?      Yes           No
                    (Attach an explanation of a “Yes” answer.)


 SECOND FELLOWSHIP

Institution Name:
Department Chair or Program Director:
                                          Last Name                       First Name              MI       Degree
Mailing Address:
                    Street                                                City                  State    Zip

Telephone Number: (          )            Fax Number: (      )
Dates attended:      From:               To:
                             mm/yy             mm/yy
Type of fellowship:
Did you successfully complete this program?            Yes       No         If no, please attach an explanation.
Were you the subject of any disciplinary action during your attendance at this institution?      Yes           No
                    (Attach an explanation of a “Yes” answer.)
If more than two fellowships, please check here and attach additional information that duplicates the information
requested above:




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Health Care Professionals Credentialing & Business Data Gathering Form                                              11
Applicant Name:
 TEACHING EXPERIENCE/FACULTY APPOINTMENT (MOST RECENT)

Institution Name:
Department Chair or Program Director:
                                           Last Name                       First Name              MI       Degree
Mailing Address:
                    Street                                                 City                   State   Zip

Telephone Number: (          )             Fax Number: (     )
Dates:    From:                  To:                    Rank/Position, if applicable:
                  mm/yy                mm/yy

Were you the subject of any disciplinary action during your attendance at this institution?       Yes           No
                    (Attach an explanation of a “Yes” answer.)


 TEACHING EXPERIENCE/FACULTY APPOINTMENT (PREVIOUS)

Institution Name:
Department Chair or Program Director:
                                           Last Name                       First Name              MI       Degree
Mailing Address:
                    Street                                                 City                   State   Zip

Telephone Number: (          )             Fax Number: (     )
Dates:    From:                  To:                    Rank/Position, if applicable:
                  mm/yy                mm/yy

Were you the subject of any disciplinary action during your attendance at this institution?       Yes           No
                    (Attach an explanation of a “Yes” answer.)
If more than two teaching experiences/faculty appointments, please check here and attach additional information
that duplicates the information requested above:




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Health Care Professionals Credentialing & Business Data Gathering Form                                               12
Applicant Name:
                     MEMBERSHIP STATUS – USE FOR SECTIONS E, F, AND G

         Please use the following key to indicate membership status in Sections E (Hospital
         Membership – Current and Pending), F (Hospital Membership – Previous), and G
         (Ambulatory Surgery Center Practice) below.

               A. Active                E. Suspended / Terminated/ Resigned          I. Provisional
               B. Courtesy              F. Active Provisional Staff                  J. Affiliate
               C. Consulting            G. Senior Staff                              K. Pending
               D. Adjunct               H. Associate                                 L. Other (Specify)


                SECTION E. HOSPITAL MEMBERSHIP - CURRENT AND PENDING

         Please list all hospitals at which you are a member of the Medical Staff and have clinical
         privileges or have applications for privileges pending. (Include additional sheets if more than
         three hospitals.)

A. Primary Hospital
       Hospital Name:
         Address:
                    Street                                                    City                    State    Zip
         Membership Status:                                              Dates:                     To Present
                                                                                  From (mm/yy)
         Department/Division:                                            Medical Staff Office FAX #: (         )
         Department Telephone #: (       )
         Any Limitations in Your Area of Specialty at this Hospital?



B. Other Hospital
       Hospital Name:
         Address:
                    Street                                                    City                    State    Zip
         Membership Status:                                              Dates:                     To:
                                                                                  From (mm/yy)            To (mm/yy)
         Department/Division:                                            Medical Staff Office FAX #: (         )
         Department Telephone #: (       )
         Any Limitations in Your Area of Specialty at this Hospital?




Health Care Professionals Credentialing & Business Data Gathering Form                                                 13
Applicant Name:
C. Other Hospital
       Hospital Name:
         Address:
                    Street                                                    City                 State    Zip
         Membership Status:                                              Dates:                  To:
                                                                                  From (mm/yy)         To (mm/yy)
         Department/Division:                                            Medical Staff Office FAX #: (      )
         Department Telephone #: (       )
         Any Limitations in Your Area of Specialty at this Hospital?




Check here if you have appended additional information for this section:



                             SECTION F. HOSPITAL MEMBERSHIP – PREVIOUS

         Please list all hospitals where you previously held privileges other than during your
         Internship/Residency/Fellowship. Use the Membership Status key listed prior to Section E.
         (Include additional sheets if more than three hospitals.)

A. Hospital Name:
         Address:
                    Street                                                    City                 State    Zip
         Membership Status:                                              Dates:                  To:
                                                                                  From (mm/yy)         To (mm/yy)
         Department/Division:                                            Medical Staff Office FAX #: (      )
         Department Telephone #: (       )
         Any Limitations in Your Area of Specialty at this Hospital?



B. Hospital Name:
         Address:
                    Street                                                    City                 State    Zip
         Membership Status:                                              Dates:                  To:
                                                                                  From (mm/yy)         To (mm/yy)
         Department/Division:                                            Medical Staff Office FAX #: (      )
         Department Telephone #: (       )
         Any Limitations in Your Area of Specialty at this Hospital?




Health Care Professionals Credentialing & Business Data Gathering Form                                              14
Applicant Name:
C. Hospital Name:
         Address:
                    Street                                                    City                 State    Zip
         Membership Status:                                              Dates:                  To:
                                                                                  From (mm/yy)         To (mm/yy)
         Department/Division:                                            Medical Staff Office FAX #: (      )
         Department Telephone #: (       )
         Any Limitations in Your Area of Specialty at this Hospital?



Check here if you have appended additional information for this section:



                    SECTION G. AMBULATORY SURGERY CENTER PRACTICE

         Please list all ambulatory surgery centers where you currently have or previously had
         privileges. Use the Membership Status key at the top of page 13. (Include additional sheets if
         more than three ambulatory surgery centers.)

A. Primary Ambulatory Surgery Center
       ASC Name:
         Address:
                    Street                                                    City                 State    Zip
         Telephone: (        )       Fax Number: (       )
         Membership Status:                                              Dates:                  To:
                                                                                  From (mm/yy)         To (mm/yy)

B. Other Ambulatory Surgery Center
      ASC Name:
         Address:
                    Street                                                    City                 State    Zip
         Telephone: (        )       Fax Number: (       )
         Membership Status:                                              Dates:                  To:
                                                                                  From (mm/yy)         To (mm/yy)

C. Other Ambulatory Surgery Center
      ASC Name:
         Address:
                    Street                                                    City                 State    Zip
         Telephone: (        )       Fax Number: (       )
         Membership Status:                                              Dates:                  To:
                                                                                  From (mm/yy)         To (mm/yy)



Check here if you have appended additional information for this section:


Health Care Professionals Credentialing & Business Data Gathering Form                                              15
Applicant Name:
                                        SECTION H. WORK HISTORY

         List chronologically (most recent first) all work engagements (including employment, self-
         employment, service as an independent contractor, and military service). Do not duplicate
         internship, residency, and fellowship information previously reported. If there is any gap of
         greater than 30 days in chronology, explain it on a separate page.

Current work place:
         Address:
                    Street                                                   City         State   Zip
         Telephone: (        )       Fax Number: (       )
         Title or Professional Occupation:
         Time in this employment: From:                      to Present
                                             (mm/yy)

Previous work place:
         Address:
                    Street                                                   City         State   Zip
         Telephone: (        )       Fax Number: (       )
         Title or Professional Occupation:
         Time in this employment: From:                      to:
                                             (mm/yy)               (mm/yy)

Previous work place:
         Address:
                    Street                                                   City         State   Zip
         Telephone: (        )       Fax Number: (       )
         Title or Professional Occupation:
         Time in this employment: From:                      to:
                                             (mm/yy)               (mm/yy)

Previous work place:
         Address:
                    Street                                                   City         State   Zip
         Telephone: (        )       Fax Number: (       )
         Title or Professional Occupation:
         Time in this employment: From:                      to:
                                             (mm/yy)               (mm/yy)

Previous work place:
         Address:
                    Street                                                   City         State   Zip
         Telephone: (        )       Fax Number: (       )
         Title or Professional Occupation:
         Time in this employment: From:                      to:
                                             (mm/yy)               (mm/yy)


Health Care Professionals Credentialing & Business Data Gathering Form                                   16
Applicant Name:
Previous work place:
         Address:
                    Street                                                   City             State   Zip
         Telephone: (        )       Fax Number: (       )
         Title or Professional Occupation:
         Time in this employment: From:                      to:
                                             (mm/yy)               (mm/yy)

Previous work place:
         Address:
                    Street                                                   City             State   Zip
         Telephone: (        )       Fax Number: (       )
         Title or Professional Occupation:
         Time in this employment: From:                      to:
                                             (mm/yy)               (mm/yy)

Previous work place:
         Address:
                    Street                                                   City             State   Zip
         Telephone: (        )       Fax Number: (       )
         Title or Professional Occupation:
         Time in this employment: From:                      to:
                                             (mm/yy)               (mm/yy)

Previous work place:
         Address:
                    Street                                                   City             State   Zip
         Telephone: (        )       Fax Number: (       )
         Title or Professional Occupation:
         Time in this employment: From:                      to:
                                             (mm/yy)               (mm/yy)


Check here if you have appended additional information for this section:




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Health Care Professionals Credentialing & Business Data Gathering Form                                       17
Applicant Name:
                                    SECTION I. PROFESSIONAL REFERENCES

          Please list the names of three individuals who have personal knowledge (within the past 12
          months) of your current clinical abilities, ethical character and interpersonal skills and who
          would be willing to provide this information upon request. Do not list partners or
          department chairpersons. Do not list relatives or people listed elsewhere in this
          credentialing form.


      CONFIDENTIAL INFORMATION

 1.    Name:                                                                            Title:
               Last                       First                          MI   Degree

       Specialty:
       Mailing Address:
                           Street                                               City              State    Zip
       Telephone: (    )                Fax Number: (     )
       Relationship:                                                               Years Known:

 2.    Name:                                                                            Title:
               Last                       First                          MI   Degree

       Specialty:
       Mailing Address:
                           Street                                               City              State    Zip
       Telephone: (    )                Fax Number: (     )
       Relationship:                                                               Years Known:



 3.    Name:                                                                            Title:
               Last                       First                          MI   Degree

       Specialty:
       Mailing Address:
                           Street                                               City              State    Zip
       Telephone: (    )                Fax Number: (     )
       Relationship:                                                               Years Known:




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Health Care Professionals Credentialing & Business Data Gathering Form                                           18
Applicant Name:
                        SECTION J. PROFESSIONAL HISTORY: CONFIDENTIAL



    ADVERSE OR OTHER ACTIONS

       Submit with all applications. Please answer the following questions to the best of your knowledge
       with a “yes” or “no.” If you answer “yes” to any question(s) please complete Form A. Please make
       copies of Form A as needed and complete one form for each “yes” answer.

1.        Has your license to practice in any jurisdiction ever been denied, restricted, limited,
          suspended, revoked, canceled and/or subject to probation either voluntarily or
          involuntarily, or has your application for a license ever been withdrawn?                   Yes   No

2.        Have you ever been reprimanded and/or fined, been the subject of a complaint and/or
          have you been notified in writing that you have been investigated as the possible
          subject of a criminal, civil or disciplinary action by any state or federal agency which
          licenses providers?                                                                         Yes   No
          
3.        Have you lost any board certification(s), and/or failed to recertify?                       Yes   No

4.        Have you been examined by a Certifying Board but failed to pass?                            Yes   No

5.        Has any information pertaining to you, including malpractice judgments and/or
          disciplinary action, ever been reported to the National Practitioner Data Bank (NPDB)
          and/or any other practitioner data bank?                                                    Yes   No

6.        Has your federal DEA number and/or state controlled substances license been
          restricted, limited, relinquished, suspended or revoked, either voluntarily or
          involuntarily, and/or have you ever been notified in writing that you are being
          investigated as the possible subject of a criminal or disciplinary action with respect to
          your DEA or controlled substance registration?                                             Yes   No

7.        Have you, or any of your hospital or ambulatory surgery center privileges and/or
          membership been denied, revoked, suspended, reduced, placed on probation,
          proctored, placed under mandatory consultation or non-renewed?                              Yes   No

8.        Have you voluntarily or involuntarily relinquished or failed to seek renewal of your
          hospital or ambulatory surgery center privileges for any reason?                            Yes   No

9         Have any disciplinary actions or proceedings been instituted against you and/or are
          any disciplinary actions or proceedings now pending with respect to your hospital or
          ambulatory surgery center privileges and/or your license?                                  Yes   No

10.       Have you ever been reprimanded, censured, excluded, suspended and/or disqualified
          from participating, or voluntarily withdrawn to avoid an investigation, in Medicare,
          Medicaid, CHAMPUS and/or any other governmental health-related programs?                   Yes   No

11.       Have Medicare, Medicaid, CHAMPUS, PRO authorities and/or any other third party
          payors brought charges against you for alleged inappropriate fees and/or quality-of-
          care issues?                                                                               Yes   No



    Health Care Professionals Credentialing & Business Data Gathering Form                                  19
    Applicant Name:
12.     Have you been denied membership and/or been subject to probation, reprimand,
        sanction or disciplinary action, or have you ever been notified in writing that you are
        being investigated as the possible subject of a criminal or disciplinary action by any
        health care organization, e.g. hospital, HMO, PPO, IPA, professional group or society,
        licensing board, certification board, PSRO, or PRO?                                        Yes    No

13.     Have you withdrawn an application or any portion of an application for appointment
        or reappointment for clinical privileges or staff appointment or for a license or
        membership in an IPA, PHO, professional group or society, health care entity or health
        care plan prior to a final decision to avoid a professional review or an adverse
        decision?                                                                                   Yes    No



 PROFESSIONAL LIABILITY ACTIONS

      If you answer yes to any question(s) in this section please complete FORM B. Please make copies of
      FORM B if needed, and complete one for each yes answer.

 1.     Have any professional liability judgments ever been entered against you?                    Yes    No

 2.     Have any professional liability claim settlements ever been paid by you and/or paid on
        your behalf?                                                                                Yes    No

 3.     Are there any currently pending professional liability suits, actions and/or claims filed
        against you?                                                                                Yes    No

 4.     Has any person or entity ever been sued for your clinical actions?                          Yes    No


 LIABILITY INSURANCE

          If you answer yes to this question please complete FORM C.

 Have you ever been denied or voluntarily relinquished your professional liability insurance
 coverage, and/or have had your professional liability insurance coverage canceled, non-
 renewed or limits reduced ?                                                                        Yes    No


 CRIMINAL ACTIONS

      If you answer yes to any question(s) in this section please complete FORM D. Please make copies of
      FORM D if needed, and complete one for each yes answer.

 1.     Have you been charged with or convicted of a crime (other than a minor traffic
        offense) in this or any other state or country and/or do you have any criminal charges
        pending other than minor traffic offenses in this state or any other state or country?      Yes    No

 2.     Have you been the subject of a civil or criminal complaint or administrative action or
        been notified in writing that you are being investigated as the possible subject at a
        civil, criminal or administrative action regarding sexual misconduct, child abuse,
        domestic violence or elder abuse?                                                           Yes    No

Health Care Professionals Credentialing & Business Data Gathering Form                                      20
Applicant Name:
 MEDICAL CONDITION

      If you answer yes to this question please complete FORM E.

 Do you have a medical condition, physical defect or emotional impairment which in any
 way impairs and/or limits your ability to practice medicine with reasonable skill and safety?
                                                                                                      Yes     No


 CHEMICAL SUBSTANCES OR ALCOHOL ABUSE

      If you answer yes to any question(s) in this section please complete FORM F. Please make copies of
      FORM F if needed, and complete one for each yes answer.

 1.     Are you currently engaged in illegal use of any legal or illegal substances?                  Yes     No

 2.     Do you currently overuse and/or abuse alcohol or any other controlled substances?             Yes     No

 3.     If you use alcohol and/or chemical substances, does your use in any way impair and/or
        limit your ability to practice medicine with reasonable skill and safety?                     Yes     No

 4.     Are you currently participating in a supervised rehabilitation program and/or
        professional assistance program which monitors you for alcohol and/or substance
        abuse?                                                                                        Yes     No


 INVESTMENTS

 In the last five (5) years have you and/or a member of your family purchased or made an
 investment in (other than securities of a publicly traded company), or otherwise have a
 business interest in any clinical laboratory, diagnostic or testing center, hospital, surgicenter,
 and/or other business dealing with the provision of ancillary health services, equipment or
 supplies?                                                                                            Yes     No

If Yes, please provide explanation:




                                                                                       (Please continue next page)




Health Care Professionals Credentialing & Business Data Gathering Form                                          21
Applicant Name:
                                              CHAPTER B:
                                         BUSINESS INFORMATION

                                 SECTION K. PRIMARY SITE INFORMATION

Please provide the following information for the primary site at which you practice.


Primary
                 Group/Business Name
  Site

                 Building Name


                 Office Address – Number and Street – Suite

                 City                                                     County                       State   Zip
                 ( )
                 Main Telephone Number           Office Administrator – Last                   First                 MI
                 ( )                             ( )
                 Beeper Number                   FAX Number                      E-mail
                 ( )                             ( )
                 Emergency Number                Answering Service
Specialty practiced at this site:

Is your practice restricted within your specialty (e.g., by age or type of patient)?           Yes        No
    If yes, describe the restrictions:


Briefly describe your practice at this location, including any special practice focus or equipment:


Are you currently accepting new patients at this location?          Yes              No
    If yes, describe any restrictions (e.g., appointment type, patient type):


Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year:

Indicate your office schedule at this location in the following table.                    Write your specific hours in the
appropriate spaces for each day:
              Monday         Tuesday       Wednesday          Thursday               Friday       Saturday      Sunday
 Hours
            to              to             to                to                 to                to           to


Health Care Professionals Credentialing & Business Data Gathering Form                                                    22
Applicant Name:
Please indicate standard patient waiting times to schedule an appointment at this site for:

                                                                          New Patient           Existing Patient
          Emergency Care
          Urgent Care
          Symptomatic Care (e.g., sore throat)
          Routine Visits (e.g., blood pressure check)
          Preventive Routine Care (e.g., school or annual physical)

Please provide the following regarding your practice at this site:

   Maximum Number of Appointments per Hour
   Average Waiting Time in Office (from scheduled appointment time to actual examination)
   Average Response Time for Returning             Acute or Urgent Situation:
   Patient Calls:
                                                   Emergency Situation:
                                                   Routine Call:

Please check all procedures you perform at this site:
         Age-appropriate immunizations                     EKG                                   Drawing blood
         Tympanometry/audiometry screening                 X-rays                                Minor surgery
         Pulmonary function studies                        Flexible sigmoidoscopy                Laceration repair
         Office gynecology (routine pelvic/PAP)            Asthma treatment                      Allergy skin testing
         Osteopathic /Chiropractic manipulation            IV hydration/treatment                Physical Therapy
List any special skills or qualifications you or your office staff have that enhance your ability to practice
medicine or treat certain patients or classes of patients. List separately any special language skills, such as
fluency in a foreign language or proficiency in sign language.
    Special Skills of Practitioner:
    Special Skills of Staff:
    Languages Spoken by Practitioner:
    Languages Written by Practitioner:
    Languages Spoken by Staff:
    Languages Written by Staff:

Is this practice site handicapped accessible (check all that apply)?
                       Building       Parking            Wheelchair             Restroom
Does this site employ paraprofessionals for direct patient care?                Yes        No
          If yes, is supervision always provided on premises during paraprofessionals’ direct patient care?
                       Yes        No
                   Do the paraprofessional(s) bill under any of your Tax ID Numbers?        Yes        No

          If yes, list Tax ID Numbers used:                        CONFIDENTIAL INFORMATION



Health Care Professionals Credentialing & Business Data Gathering Form                                                  23
Applicant Name:
Lab Service at this site?           Yes        No
                               If yes, check whether:       Primary           Secondary      Tertiary
         CLIA Waiver:          Yes        No
                            If yes, CLIA Expiration Date:

Please provide the following information about physician(s)/practitioner(s) who provide coverage for patients
enrolled at this site when you are not available.
Name:
        Last                                            First                        MI    Degree
         Specialty:
         Address:                                                                     Telephone: (      )
                   Street                               City      State Zip
         Availability:       Days         Nights         Weekends       Holidays

         CONFIDENTIAL INFORMATION: Tax ID #:

Name:
        Last                                            First                        MI    Degree
         Specialty:
         Address:                                                                     Telephone: (      )
                   Street                               City      State Zip
         Availability:       Days         Nights         Weekends       Holidays

         CONFIDENTIAL INFORMATION: Tax ID #:

Name:
        Last                                            First                        MI    Degree
         Specialty:
         Address:                                                                     Telephone: (      )
                   Street                               City      State Zip
         Availability:       Days         Nights         Weekends       Holidays

         CONFIDENTIAL INFORMATION: Tax ID #:


Please provide the following information about physician(s)/practitioner(s) who practice in this office:
Name:                                                                                 Specialty:
        Last                                   First                     MI
Name:                                                                                 Specialty:
        Last                                   First                     MI
Name:                                                                                 Specialty:
        Last                                   First                     MI




Health Care Professionals Credentialing & Business Data Gathering Form                                      24
Applicant Name:
                           SECTION L. PRIMARY SITE TAX INFORMATION

         Please provide the following information for your Primary Site. Include tax information for
         each business arrangement you use at this site. (Please include additional sheets if more than
         four applicable business arrangements.)


Business Arrangement #1
Name of Business Arrangement On SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):

 CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site: (        )

Business Arrangement #2
Name of Business Arrangement On SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):

 CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site: (        )

Business Arrangement #3
Name of Business Arrangement On SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):

 CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site: (        )

Business Arrangement #4
Name of Business Arrangement On SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):

 CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site: (        )




Health Care Professionals Credentialing & Business Data Gathering Form                                    25
Applicant Name:
                             SECTION M. ADDITIONAL SITE INFORMATION

Please provide the following information for each additional site at which you practice.


   Site
                 Group/Business Name
   #

                 Building Name


                 Office Address – Number and Street – Suite

                 City                                                     County                       State   Zip
                 ( )
                 Main Telephone Number           Office Administrator – Last                   First                 MI
                 ( )                             ( )
                 Beeper Number                   FAX Number                      E-mail
                 ( )                             ( )
                 Emergency Number                Answering Service
Specialty practiced at this site:

Is your practice restricted within your specialty (e.g., by age or type of patient)?           Yes        No
    If yes, describe the restrictions:


Briefly describe your practice at this location, including any special practice focus or equipment:


Are you currently accepting new patients at this location?          Yes              No
    If yes, describe any restrictions (e.g., appointment type, patient type):


Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year:

Indicate your office schedule at this location in the following table.                    Write your specific hours in the
appropriate spaces for each day:
              Monday         Tuesday       Wednesday          Thursday               Friday       Saturday      Sunday
 Hours
            to              to             to                to                 to                to           to




Health Care Professionals Credentialing & Business Data Gathering Form                                                    26
Applicant Name:
Please indicate standard patient waiting times to schedule an appointment at this site for:

                                                                          New Patient           Existing Patient
          Emergency Care
          Urgent Care
          Symptomatic Care (e.g., sore throat)
          Routine Visits (e.g., blood pressure check)
          Preventive Routine Care (e.g., school or annual physical)

Please provide the following regarding your practice at this site:

   Maximum Number of Appointments per Hour
   Average Waiting Time in Office (from scheduled appointment time to actual examination)
   Average Response Time for Returning             Acute or Urgent Situation:
   Patient Calls:
                                                   Emergency Situation:
                                                   Routine Call:

Please check all procedures you perform at this site:
         Age-appropriate immunizations                     EKG                                   Drawing blood
         Tympanometry/audiometry screening                 X-rays                                Minor surgery
         Pulmonary function studies                        Flexible sigmoidoscopy                Laceration repair
         Office gynecology (routine pelvic/PAP)            Asthma treatment                      Allergy skin testing
         Osteopathic /Chiropractic manipulation            IV hydration/treatment                Physical Therapy
List any special skills or qualifications you or your office staff have that enhance your ability to practice
medicine or treat certain patients or classes of patients. List separately any special language skills, such as
fluency in a foreign language or proficiency in sign language.
    Special Skills of Practitioner:
    Special Skills of Staff:
    Languages Spoken by Practitioner:
    Languages Written by Practitioner:
    Languages Spoken by Staff:
    Languages Written by Staff:

Is this practice site handicapped accessible (check all that apply)?
                       Building       Parking            Wheelchair             Restroom
Does this site employ paraprofessionals for direct patient care?                Yes        No
          If yes, is supervision always provided on premises during paraprofessionals’ direct patient care?
                       Yes        No
                   Do the paraprofessional(s) bill under any of your Tax ID Numbers?        Yes        No

          If yes, list Tax ID Numbers used:                        CONFIDENTIAL INFORMATION



Health Care Professionals Credentialing & Business Data Gathering Form                                                  27
Applicant Name:
Lab Service at this site?           Yes        No
                               If yes, check whether:       Primary           Secondary      Tertiary
         CLIA Waiver:          Yes        No
                            If yes, CLIA Expiration Date:

Please provide the following information about physician(s)/practitioner(s) who provide coverage for patients
enrolled at this site when you are not available.
Name:
        Last                                            First                        MI    Degree
         Specialty:
         Address:                                                                     Telephone: (      )
                   Street                               City      State Zip
         Availability:       Days         Nights         Weekends       Holidays

         CONFIDENTIAL INFORMATION: Tax ID #:

Name:
        Last                                            First                        MI    Degree
         Specialty:
         Address:                                                                     Telephone: (      )
                   Street                               City      State Zip
         Availability:       Days         Nights         Weekends       Holidays

         CONFIDENTIAL INFORMATION: Tax ID #:

Name:
        Last                                            First                        MI    Degree
         Specialty:
         Address:                                                                     Telephone: (      )
                   Street                               City      State Zip
         Availability:       Days         Nights         Weekends       Holidays

         CONFIDENTIAL INFORMATION: Tax ID #:

Please provide the following information about physician(s)/practitioner(s) who practice in this office:
Name:                                                                                 Specialty:
        Last                                   First                     MI
Name:                                                                                 Specialty:
        Last                                   First                     MI
Name:                                                                                 Specialty:
        Last                                   First                     MI




Health Care Professionals Credentialing & Business Data Gathering Form                                      28
Applicant Name:
                         SECTION N. ADDITIONAL SITE TAX INFORMATION

Please provide the following information for each additional site at which you practice. Include tax
information for each business arrangement you use at this site. (If there is more than one additional site, or
more than five business arrangements at any one site, please copy and complete this page for each additional site
and business arrangement.)


Business Arrangement #1
Name of Business Arrangement On SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):

 CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site: (        )

Business Arrangement #2
Name of Business Arrangement On SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):

 CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site: (        )

Business Arrangement #3
Name of Business Arrangement On SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):

 CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site: (        )

Business Arrangement #4
Name of Business Arrangement On SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):

 CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site: (        )


                     End Credentialing and Business Data Gathering Form.
                               Attach Forms A-F As Required.
Health Care Professionals Credentialing & Business Data Gathering Form                                              29
Applicant Name:
                             FORM A – ADVERSE AND OTHER ACTIONS

         DUPLICATE this form as necessary to complete separate sheet for EACH occurrence that
         applies. Use reverse side of this form if additional space is needed.


Applicant Name:
                   Last                                             First                                MI

Indicate the number of ONE of the questions in Section J to which you answered “yes”: Question Number:


A. Describe the circumstances surrounding this occurrence. Please include the date of the occurrence.




B. Provide an explanation of any actions taken. Please include the date the action was taken.




C. Provide the current status of the issue.




D. If known:      Contact:

                  Department/Committee:

                  Address:
                              Street                                        City                State   Zip
                  Telephone: (      )



Signature:                                                                          Date:




Health Care Professionals Credentialing & Business Data Gathering Form                                        FORM A
Applicant Name:
                          FORM B – PROFESSIONAL LIABILITY ACTIONS

         DUPLICATE this form as necessary to complete a separate sheet for EACH action or
         allegation. Use reverse side of this form if additional space is needed.


Applicant Name:
                   Last                                             First                           MI

A. Plaintiff’s Name:
                       Last                                              First                           MI

         If court case, Case Name & Case Number:



B. Your Involvement in the Care (Attending, Consulting, Etc.):

C. Your Status in the Case (Sole Defendant, Co-Defendant, Ownership Interest in Provider Practice Name in
   Suit, Etc.):

D. Allegations, including Patient Outcome, if Available:




E. Date of Incident (mm/yy):                                     F. Date Filed (mm/yy):

G. Date Case Closed (mm/yy):

   Resolution Case:             Dismissed                     Judgment           Arbitration   Other
                               Settlement out of Court       Pending            Mediation

H. Amount Paid on Your Behalf (if any): $

I. Professional Liability Insurer Name (if one was involved):

J. Insurer Telephone Number: (         )                         K. Policy Number:

L. Insurer Address (Street, City, State, Zip Code):




Signature:                                                                             Date:




Health Care Professionals Credentialing & Business Data Gathering Form                                   FORM B
Applicant Name:
                                   FORM C – LIABILITY INSURANCE

         DUPLICATE this form as necessary to complete a separate sheet for EACH action or
         allegation. Use reverse side of this form if additional space is needed.


Applicant Name:
                   Last                                             First                MI

A. History of Professional Liability Insurance (Please check One)

             Canceled Voluntarily                           Non-Renewed

             Canceled Involuntarily                         Application Denied

B. Carrier Name:

C. Carrier Telephone Number: (        )

D. Policy Number:

E. Carrier Address (Street, City, State, Zip Code):




F. Dates of Coverage:     From (mm/yy):                        To (mm/yy):

G. Circumstances Involved:




Signature:                                                                       Date:




Health Care Professionals Credentialing & Business Data Gathering Form                        FORM C
Applicant Name:
                                     FORM D – CRIMINAL ACTIONS

         DUPLICATE this form as necessary to complete a separate sheet for EACH incident. Use
         reverse side of this form if additional space is needed.


Applicant Name:
                    Last                                            First                 MI

A. Date of Incident (mm/yy):

B. Date of Complaint or Conviction (mm/yy):

C. Date of Resolution (mm/yy):

D. Type of Resolution (Dismissed, Plea Bargain, Misdemeanor, Felony):

E. Allegation(s):




F. Details of Incident:




G. Actions Taken Against You:




H. Current Status of Situation:




I. Medical Practice Privileges Affected as a Result of This Situation:




Signature:                                                                  Date:



Health Care Professionals Credentialing & Business Data Gathering Form                          FORM D
Applicant Name:
                                    FORM E – MEDICAL CONDITION

          DUPLICATE this form as necessary to complete a separate sheet for EACH condition. Use
          reverse side of this form if additional space is needed.


Applicant Name:
                   Last                                             First                                 MI

A. Describe this medical condition:




B. To what extent does or could this condition affect your current ability to practice medicine in your specialty
   area or to perform a full range of clinical activities?




C. What is the current status of your condition?




D. Provide the name and address of your personal physician/health care provider who can provide information
   about your health condition.

   Name                                                                              Telephone Number

                                                                                           (    )
   Last                                   First                      MI     Degree

                                                                                           (    )
   Last                                   First                      MI     Degree



Signature:                                                                              Date:




Health Care Professionals Credentialing & Business Data Gathering Form                                         FORM E
Applicant Name:
                 FORM F – CHEMICAL SUBSTANCES OR ALCOHOL ABUSE

         DUPLICATE this form as necessary to complete a separate sheet for EACH chemical
         substance incident. Use reverse side of this form if additional space is needed.


Applicant Name:
                    Last                                            First                               MI

Describe the substance you use:


A. To what extent does, or could, your use of this substance affect your current ability to practice medicine in your
   specialty area or to perform a full range of clinical activities?




B. Monitored by State Board Mandate (Name and Address)           C. Monitored Voluntarily (Name and Address)




D. Other information about the current status of your use of substances:




E. Abstinent since (mm/yy):

F. Provide the name and address of your personal physician/health care provider who can provide information about
   your treatment for alcohol or chemical substance use and can comment on what impact (if any) it has on your
   current/future professional practice.


         Name:

         Address:
                  Street                                                    City              State    Zip
         Telephone: ( )


Signature:                                                                           Date:




Health Care Professionals Credentialing & Business Data Gathering Form                                       FORM F
Applicant Name:
              PROVIDER ATTESTATION AND
CONSENT FOR RELEASE OF INFORMATION/ RELEASE FROM LIABILITY


I hereby affirm and attest that all statements, answers, and information contained in this
application are correct and complete to the best of my knowledge, information, and
belief. I understand that falsification, misrepresentation, or omission of any fact(s)
requested will sufficient cause for denial of this application and/or subsequent
termination of any participating privileges granted upon the basis of this application.

I hereby give permission to Coventry Health Care of Illinois, Inc. (“Coventry Health
Care”) its affiliates and the employees, agents and representatives thereof to obtain
information about my professional education, Training, licensing, competence, ethics,
character and other qualifications. I consent to the release of such information, whether in
the form of transcripts, records, tapes, letters, photocopies/duplications of any of the
foregoing, or verbal statements, by hospital administrators, chiefs of clinical departments
of hospitals in which I have served on staff, state licensing boards or regulatory bodies
(by whatever name known in their respective jurisdictions), physicians, clinics, or other
individuals or organizations who or which may possess information about me. Such
information may be released to the above named entity and its affiliates or to
representatives of such entity and its affiliates.

I hereby release from liability and agree to hold harmless any person or entity who or
which provides the above described information as authorized herein.

I hereby release from liability and agree to hold harmless all employees, agents and
representatives of the above named entity and its affiliates for their acts performed and
statements made in connection with obtaining, reviewing, and evaluating my credentials
and qualifications. I further acknowledge my cooperation by consenting to the production
of my provider name, specialty and contact information to be included in the Coventry
Health Care Provider Directory. The determination of whether I am qualified to serve as
a provider of services is the reason such information is needed for review and evaluation
by the above-named organization and their representatives.

In the event I am accepted for participation in Coventry Health Care I hereby consent to
Coventry Health Care’s inspection of my patient records relating to Coventry Health Care
enrollees as necessary for its peer, utilization and quality review processes and agree to
be bound by Coventry Health Care’s provider agreement, credentialing plan and provider
manual.

I further agree that a photocopy of this document will serve as a duplicate original.

Print Name:___________________________________________Date:______________

Signature:_______________________________________________________________


Provider Attestation Form 08 13 2003         1
Revised 11/2011
Form
(Rev. January 2005)
                                       W-9                                          Request for Taxpayer                                                       Give form to the
                                                                                                                                                               requester. Do not
Department of the Treasury
                                                                          Identification Number and Certification                                              send to the IRS.
Internal Revenue Service
                                       Name (as shown on your income tax return)
See Specific Instructions on page 2.




                                       Business name, if different from above
           Print or type




                                                                     Individual/                                                                                Exempt from backup
                                       Check appropriate box:        Sole proprietor     Corporation       Partnership   Other                                  withholding
                                       Address (number, street, and apt. or suite no.)                                            Requester’s name and address (optional)


                                       City, state, and ZIP code


                                       List account number(s) here (optional)


      Part I                                 Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid                                         Social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident                                                  –           –
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.                                                         or
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number                                        Employer identification number
to enter.                                                                                                                                           –
      Part II                                Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
   Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
   notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4.)

Sign                                       Signature of
Here                                       U.S. person                                                                           Date

Purpose of Form
A person who is required to file an information return with the                                              ● Any estate (other than a foreign estate) or trust. See
IRS, must obtain your correct taxpayer identification number                                                 Regulations sections 301.7701-6(a) and 7(a) for additional
(TIN) to report, for example, income paid to you, real estate                                                information.
transactions, mortgage interest you paid, acquisition or                                                     Foreign person. If you are a foreign person, do not use
abandonment of secured property, cancellation of debt, or                                                    Form W-9. Instead, use the appropriate Form W-8 (see
contributions you made to an IRA.                                                                            Publication 515, Withholding of Tax on Nonresident Aliens
U.S. person. Use Form W-9 only if you are a U.S. person                                                      and Foreign Entities).
(including a resident alien), to provide your correct TIN to the                                             Nonresident alien who becomes a resident alien.
person requesting it (the requester) and, when applicable, to:                                               Generally, only a nonresident alien individual may use the
   1. Certify that the TIN you are giving is correct (or you are                                             terms of a tax treaty to reduce or eliminate U.S. tax on
waiting for a number to be issued),                                                                          certain types of income. However, most tax treaties contain a
                                                                                                             provision known as a “saving clause.” Exceptions specified
   2. Certify that you are not subject to backup withholding,                                                in the saving clause may permit an exemption from tax to
or                                                                                                           continue for certain types of income even after the recipient
   3. Claim exemption from backup withholding if you are a                                                   has otherwise become a U.S. resident alien for tax purposes.
U.S. exempt payee.
 Note. If a requester gives you a form other than Form W-9 to                                                   If you are a U.S. resident alien who is relying on an
request your TIN, you must use the requester’s form if it is                                                 exception contained in the saving clause of a tax treaty to
substantially similar to this Form W-9.                                                                      claim an exemption from U.S. tax on certain types of income,
                                                                                                             you must attach a statement to Form W-9 that specifies the
   For federal tax purposes you are considered a person if you                                               following five items:
are:                                                                                                            1. The treaty country. Generally, this must be the same
● An individual who is a citizen or resident of the United                                                   treaty under which you claimed exemption from tax as a
States,                                                                                                      nonresident alien.
● A partnership, corporation, company, or association                                                           2. The treaty article addressing the income.
created or organized in the United States or under the laws
                                                                                                                3. The article number (or location) in the tax treaty that
of the United States, or
                                                                                                             contains the saving clause and its exceptions.
                                                                                                   Cat. No. 10231X                                           Form   W-9   (Rev. 1-2005)
Form W-9 (Rev. 1-2005)                                                                                                                            Page      4
Part II. Certification                                                 What Name and Number To Give the
To establish to the withholding agent that you are a U.S.              Requester
person, or resident alien, sign Form W-9. You may be
                                                                       For this type of account:                   Give name and SSN of:
requested to sign by the withholding agent even if items 1, 4,
and 5 below indicate otherwise.                                            1. Individual                           The individual
   For a joint account, only the person whose TIN is shown in              2. Two or more individuals (joint       The actual owner of the account
Part I should sign (when required). Exempt recipients, see                    account)                             or, if combined funds, the first
Exempt From Backup Withholding on page 2.                                                                          individual on the account 1
Signature requirements. Complete the certification as                      3. Custodian account of a minor         The minor 2
indicated in 1 through 5 below.                                               (Uniform Gift to Minors Act)
                                                                                                                                              1
                                                                           4. a. The usual revocable               The grantor-trustee
  1. Interest, dividend, and barter exchange accounts                            savings trust (grantor is
opened before 1984 and broker accounts considered                                also trustee)
active during 1983. You must give your correct TIN, but you                   b. So-called trust account           The actual owner       1
do not have to sign the certification.                                           that is not a legal or valid
   2. Interest, dividend, broker, and barter exchange                            trust under state law
accounts opened after 1983 and broker accounts                             5. Sole proprietorship or               The owner      3

considered inactive during 1983. You must sign the                            single-owner LLC
certification or backup withholding will apply. If you are             For this type of account:                  Give name and EIN of:
subject to backup withholding and you are merely providing
                                                                                                                                  3
your correct TIN to the requester, you must cross out item 2               6. Sole proprietorship or               The owner
in the certification before signing the form.                                 single-owner LLC
                                                                                                                                      4
   3. Real estate transactions. You must sign the                          7. A valid trust, estate, or            Legal entity
certification. You may cross out item 2 of the certification.                 pension trust
  4. Other payments. You must give your correct TIN, but                   8. Corporate or LLC electing            The corporation
you do not have to sign the certification unless you have                     corporate status on Form
been notified that you have previously given an incorrect TIN.                8832
“Other payments” include payments made in the course of
the requester’s trade or business for rents, royalties, goods              9. Association, club, religious,        The organization
(other than bills for merchandise), medical and health care                   charitable, educational, or
services (including payments to corporations), payments to a                  other tax-exempt organization
nonemployee for services, payments to certain fishing boat
                                                                       10. Partnership or multi-member             The partnership
crew members and fishermen, and gross proceeds paid to                     LLC
attorneys (including payments to corporations).
   5. Mortgage interest paid by you, acquisition or                    11. A broker or registered                  The broker or nominee
abandonment of secured property, cancellation of debt,                     nominee
qualified tuition program payments (under section 529),                12. Account with the Department             The public entity
IRA, Coverdell ESA, Archer MSA or HSA contributions or                     of Agriculture in the name of
distributions, and pension distributions. You must give                    a public entity (such as a
your correct TIN, but you do not have to sign the                          state or local government,
certification.                                                             school district, or prison) that
                                                                           receives agricultural program
                                                                           payments
                                                                       1
                                                                           List first and circle the name of the person whose number you furnish. If
                                                                           only one person on a joint account has an SSN, that person’s number must
                                                                           be furnished.
                                                                       2
                                                                           Circle the minor’s name and furnish the minor’s SSN.
                                                                       3
                                                                         You must show your individual name and you may also enter your business
                                                                         or “DBA” name on the second name line. You may use either your SSN or
                                                                         EIN (if you have one). If you are a sole proprietor, IRS encourages you to
                                                                         use your SSN.
                                                                       4
                                                                         List first and circle the name of the legal trust, estate, or pension trust. (Do
                                                                         not furnish the TIN of the personal representative or trustee unless the legal
                                                                         entity itself is not designated in the account title.)
                                                                       Note. If no name is circled when more than one name is
                                                                       listed, the number will be considered to be that of the first
                                                                       name listed.

Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or
abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS
uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this
information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry
out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to
enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
   You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable
interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
                                                           ELECTRONIC FUND TRANSFER
                                                             AUTHORIZATION FORM
                                                                   Please return to the address below:
                                                                   Coventry Health Care, Inc.
                                                                   Attn: PC&I-EST
                                                                   PO Box 67103
                                                                   Harrisburg, PA 17106-7103

Request Type:    New Provider          Update to Existing Provider EFT Information
The undersigned health care provider (“Provider”) hereby: (1) authorizes Coventry Health Care, Inc. and its
affiliates (“Coventry”) to make payments for Provider’s services by Electronic Fund Transfer (EFT), (2)
certifies that Provider has selected the following depository institution, and (3) directs that all such EFT
payments be made as provided below. (4) Provider also acknowledges and agrees that by completing this
form, Provider will no longer receive paper remittance advices by mail rather Provider will obtain the
remittance advices on Coventry’s provider portal www.directprovider.com.
Provider Name: ___________________________________________________________________________

Provider’s Tax ID: _______________________         Provider’s Group NPI #: __________________________

Provider Contact Name: ________________________________            Phone Number: _____________________

Contact Email: ________________________________________________ Fax #: _____________________

Depository Institution: _____________________________________________________________________

Address: ________________________________________________________________________________

Bank Routing Number: _____________________________________________________________________

Account Number: _________________________________________________________________________

Account Name: ___________________________________________________________________________

Account Type:          Checking              Savings      (must choose one)

This Authorization will remain in effect until Coventry receives notification of termination from Provider.
Provider will give thirty (30) days advance notice in writing to Coventry Health Care, Inc. of termination or
any changes in its depository institution or other payment instructions. When properly executed, this
Authorization will become effective thirty (30) days after its receipt by Coventry Health Care, Inc. Coventry
reserves the right to recall an incorrect EFT transaction within 5 days.
Before submitting this Authorization form, Provider should check with its banking institution to verify that it
will be able to receive Automated Clearing House (ACH) transactions and if there are any associated fees for
this service. To ensure the correct banking information is entered into our system, please enclose a voided
check, deposit slip, or letter from your banking institution indicating the appropriate account and financial
institution routing numbers.
The undersigned person represents and warrants that he/she is authorized to execute this form on behalf of the
Provider.
Authorized Signature: ____________________________________            Date: _______________________

Print Name: ____________________________________________              Title: _______________________
                                     COVENTRY HEALTH CARE OF ILLINOIS, INC.


    APPLICANT RIGHTS FOR CREDENTIALING AND RECREDENTIALING

   Applicants have the right, upon request, to be informed of the status of their application.
    Applicants may contact credentialing staff via telephone or in writing to inquire as to the status
    of their application.

   Credentialing staff will respond to the applicant's request for information either via telephone or
    in writing of the status of their application. Coventry Health Care of Missouri, Inc. (Coventry) is
    not required to provide the applicant with information that is peer-review protected.
    Information reported to the National Practitioner Data Bank (NPDB) is considered confidential
    and shall not be disclosed. An applicant will be advised that they may complete a self-query to
    obtain information that is contained in the NPDB.

   Applicants have the right to review the information submitted in support of their credentialing
    application. This review is at the applicant's request.

   The applicant will be notified in writing of initial credentialing decisions within sixty (60) days of
    being reviewed for credentialing.

   Credentialing staff will notify the applicant in writing of any information obtained during the
    credentialing process that varies significantly from the information provided to the Health Plan
    by the applicant.

   Should the information provided by the applicant on their application vary substantially from
    the information obtained and/or provided to Coventry by other individuals or organizations
    contact as part of the credentialing and/or recredentialing process, credentialing staff will
    contact the applicant via fax or postal mail within 180 days from the date of the signed
    attestation and authorization statement to advise the applicant of the variance and provide the
    applicant with the opportunity to correct the information if it is erroneous.

   The applicant will submit any corrections in writing within fourteen (14) calendar days to the
    credentialing staff. Any additional documentation will be kept as part of the applicant's
    credential file.




        This document and the information herein is the sole proprietary information of Coventry Health Care of Illinois, Inc.

				
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